Medical Minute: Cervical (carotid and vertebral) artery dissections

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January 2, 2015 by dailybolusoflr

By: Marrissa Baker, MD
Case:
A 55 year-old male with a history of CAD s/p CABG, DM, left fem-pop bypass p/w headache and left neck pain x 2 days. He states that he can hear his heart beat in his left ear. His exam is remarkable for tenderness to palpation on the left neck and a normal neuro exam.
Pathophysiology:
Inner lining of arterial wall is disrupted and blood extends between layers of the blood vessel wall. As the layers of the arterial wall fill, the inner lumen may be compressed or an aneurysm may form. Ischemic stroke may occur to either occlusion of the vessel (from compression or occult thrombus at dissection site) or from emboli from thrombi (formed due to turbulence and exposed endothelial factors)
Epidemiology:
  • Cause of stroke in 8-10% of patients under age 40
  • Spontaneous incidence 3-5/100,000 for carotid, 1/100,000 for vertebral
  • Traumatic incidence 1/1000

Presentation:
  • Pain from damage to artery lining
  • Headache
  • CVA/TIA

Carotid:weakness, sensory loss, slurred speech, aphasia, monocular vision changes, cranial nerve palsy, dysgeusia, pulsatile tinnitus
Vertebral:dizziness, incoordination, unilateral facial paresthesias, disequilibrium, vertigo with nystagmus, lateral medullary syndrome, locked-in syndrome, respiratory failure, binocular visual loss
Diagnosis:
  • Because the signs and symptoms are similar to more common etiologies, diagnosis is dependent on a high level of suspicion. Perform a good neuro exam!
  • CTA or MRA of head and/or neck

Treatment:
  • Patients with ischemic neurologic deficits are candidates for tPA or endovascular stroke therapy (but should not be given if the dissection enters the skull or if there is aortic involvement)
  • Anticoagulation or antiplatelet therapy is indicated for all dissections

Reference:

Shea K and Stahmer S. Carotid and vertebral arterial dissections in the emergency department. Emergency Medicine Practice. 2012 April; 14:4

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